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Application Form for Admission
Patient’s Name : *
S/o, W/o, D/o : *
Date of Birth : *
Male / Female : *
Male Female
Marital Status : *
Married Single
Address 1 : *
Address 2 :
Phone No :
E-mail : *
Occupation : *
Nationality / Passport No. : *
Accommodation Required. : *
Yes No
No of Days. : *
Days
Room Booking Date. : *
From
 
To
Previous Admission Date. :
Registration Number. :
Height and Weight. :
Height Weight
Any complaints or Diseases. :
Duration of the Disease. :
Area of body pain. :
Do you have any kind of Skin problem?. : *
Yes No
Do you have any general or food allergy? : *
Yes No
How is your Bowel Movement? :
Any urinary problem? : *
Yes No
Any history of Blood Pressure/Diabetes/heart ailments etc? : *
Yes No
Operations Undergone :
Present Medication in detail :
Please mention about your recent medical lab reports :
How is your Menstrual Cycle :
No of Children :
Do you suffer from any type of Ulcer or Hernia? :
Any Habits/addictions? :
Are you physically fit, to walk? If no, give details :
Mention about your present daily physical activities/exercise/yoga, etc :
I have read the conditions mentioned in the Rules and regulations page. I hereby accept and solemnly undertake that I shall abide by all the rules and conventions of kayakalp as mentioned in website and brochure. The possible benefits and risks are understood by me. I opt for treatment on my own accord. In case of adversities / complications during my stay at Kayakalp, the management will not be held responsible and it has the right to shift / refer me to a suitable medical Institution for necessary treatment, at my cost.
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Security Code : *
Represents compulsory fields : *